What does vulvar vestibulitis look like

A version of vestibuloplasty that denervates the vestibule with incision, undercutting, and closure of the mucosa without excising the painful tissue or increasing the caliber of the introitus has been completely unsuccessful. Vestibulectomy excises the vestibule with vaginal advancement. The surgeon excises a U-shaped area of the vestibule from 5 mm lateral to the urethra to the posterior fourchette.

The hymenal ring is included. The margins of the vestibule are reapproximated to the vaginal wall Figure 2. To cover that excised area posteriorly, a piece of posterior vaginal wall is dissected from the underlying tissue. Perineoplasty involves excision of the vestibule with vaginal advancement overlying a portion of excised perineum.

The U-shaped excision includes the hymeneal ring and vestibule. Through a U-shaped perineal incision, the vagina is mobilized and the vaginal mucosa is undermined for an additional 1 to 2 cm and advanced to cover the perineal defect. Large variations exist, however. Factors that limit direct comparison are differences in numbers of patients, presence of associated symptoms like urinary tract symptoms, other medical treatment at the time of surgery, technique used, definition of success, and length of follow-up.

But first and foremost, patient selection is crucial. Pain must be confined to the vestibule and existing vaginismus must be treated. A surgical approach was successful in a randomized clinical trial that compared three treatments for VVS: cognitive-behavioral therapy, surface electromyographic biofeedback, and vestibulectomy perineoplasty.

The surgical group, however, had significantly better outcome measures of pain reduction and improved sexual functioning than the other two groups.

Stewart and co-author Paula Spencer have written a book on vulvovaginal health and disease, The V Book: A Doctor's Guide to Complete Vulvovaginal Health New York, Bantam, , which includes chapters on pain and sexual functioning in the presence of pain. It contains some clinical references from medical journals.

More information is available on her Web site, www. Biopsychosocial profile of women with dyspareunia. Obstet Gynecol. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc. Vulvar vestibulitis: significant clinical variables and treatment outcome. Vulvar vestibulitis syndrome: an exploratory case-control study. Foster DC.

Case control study of vulvar vestibulitis. J Womens Health. Severe vulvar vestibulitis. Relation to HPV infection. J Reprod Med. Westrom LV, Willen R. Vestibular nerve fiber proliferation in vulvar vestibulitis syndrome. Increased epithelial innervation in women with vulvar vestibulitis syndrome.

Gynecol Obstet Invest. Neurochemical characterization of the vestibular nerves in women with vulvar vestibulitis syndrome. A special type of chronic pelvic pain. Obstet Gynecol Clin North Am. The treatment of vulvar vestibulitis syndrome: towards a multimodal approach. J Sex Marital Ther. Psychophysical evidence of nociceptor sensitization in vulvar vestibulitis syndrome. Is there an increased prevalence? Obstetrics and Gynecologic Dermatology. London: Mosby International Limited; Glazer HI, Rodke G.

The Vulvodynia Survival Guide: How to overcome painful vaginal symptoms and enjoy an active lifestyle. Oakland, Ca: New Harbinger Publications; Stewart EF, Spencer P. New York, NY: Bantam; Psychosomatic aspects of vulvodynia. Comparison with the chronic pelvic pain syndrome. Estrogens, the immune response and autoimmunity. Clin Exp Rheumatol. Calcium citrate for vulvar vestibulitis: a case report. Urinary oxalate secretion and its role in vulvar pain syndrome.

Am J Obstet Gynecol. Davar G, Maciewicz RJ. Overview Vulvodynia vul-voe-DIN-e-uh is chronic pain or discomfort around the opening of your vagina vulva for which there's no identifiable cause and which lasts at least three months. Vulva Open pop-up dialog box Close. Vulva The vulva is the outer part of the female genitalia, including the labia majora, labia minora and clitoris. Request an Appointment at Mayo Clinic.

Share on: Facebook Twitter. Show references Stewart EG. Clinical manifestations and diagnosis of generalized vulvodynia.

Accessed May 1, Spadt SK, et al. Treatment of vulvodynia vulvar pain of unknown cause. What is vulvodynia?. National Vulvodynia Association. Frequently asked questions. Both systemic and topical corticosteroids can also cause worsening of undiagnosed infections by counteracting the immune response that causes inflammation, but that also fights the infection as well.

There are also anecdotal reports that some women develop VVS after taking Accutane. This needs to be further studied. The Fibromyalgia Network mentions that vulvodynia is often found in women with Fibromyalgia Syndrome FMS , which is a muscular pain disorder of uncertain etiology, and which is related to Chronic Fatigue Syndrome. Abnormally high levels of a neurotransmitter involved in regulating pain sensation, called Substance P, have been found in people with FMS and it's possible that at least some cases of VVS are due to abnormalities of the pain perception mechanisms in the body.

There is also the possibility that abnormally high levels of urine oxalate may be involved. Clive Solomons, M. Melmed, and Susan Heitler of Rose Medical Center in Denver, Colorado have suggested that oxalate may be irritating the vulvar tissues during urination, and are currently conducting a study to see if neutralizing oxalates by taking oral doses of calcium citrate is of value to treat VVS.

A recent study suggests that, while oxalates may be an aggravating factor for some women with vulvodynia, it does not appear to be causative of the condition. In addition to measuring 24 hour volume and concentration, peak oxalate levels were measured by the hour. There was no difference between the vulvodynia and control groups in any of the measured oxalate parameters, although women with vulvodynia had significantly more frequent voidings.

Of this group, 59 patients were treated with a low oxalate diet and calcium citrate for 3 months and then evaluated for response. Finally, a number of immune changes have been found in vulvodynia, although their significance remains unclear.

While a detailed discussion of immunology is outside the scope of this paper, the findings are presented below:.

The Wayne State University researchers mentioned previously also found mast cells in the patient group. Mast cells are associated with inflammatory allergic reactions and are also found in interstitial cystitis.

In a study at Johns Hopkins in Baltimore, researchers looked for levels of two cytokines immune stimulating chemicals associated with inflammation: interleukin-1 beta and tumor necrosis factor-alpha. They found significantly higher levels of both these chemicals in women with VVS when compared to women without vulvar pain. Pathologists at University Hospital Dijkzigt in Rotterdam, in the Netherlands, did a histopathologic study of biopsies from 12 patients with VVS and 12 age matched controls.

They found a chronic inflammatory infiltrate in all of the patients with vestibulitis and none in the control group. This infiltrate was composed of T-lymphocytes, with small numbers of B cells, plasma cells, mast cells and occasional monocytes. This indicates chronic inflammation and possibly an autoimmune origin; however the researchers stated that an autoimmune etiology can neither be confirmed nor rejected based on this study. They also observed some possibly pre-cancerous changes in the cells of two patients mild dysplasia , which is interesting in light of the fact that neither the patient nor the control group showed any sign of carcinogenic HPV strains.

This might be partly explained by another intriguing immunologic finding. Researchers at the University of Iowa found impaired natural killer lymphocyte activity in VVS when compared to healthy controls. Natural killer cells are a key part of the body's defense system against cancers. Normally, the activity of natural killer cells increases in response to high levels of interleukin-1 and interferon-alpha.

In interstitial cystitis, cells stained with this process fluoresce. They found immnofluorescence in VVS and suggest that vascular injury associated with altered central neuronal processing could explain the positive immunofluorescence findings in both VVS and IC.

There is no specific test for vulvodynia per se. There are a number of tests that should be done to both rule out other illnesses and to look for infection or another treatable cause of the symptoms.

Many cases are initially diagnosed when women who have pain with intercourse consult a doctor. Other cases are often detected only after many failed attempts, either by the woman herself or by her physician, to treat what appears to be a chronic vaginal bacterial or yeast infection.

It's very important to seek a proper diagnosis from a physician or other qualified health provider such as a nurse practitioner or physician's assistant. This is because there are some very serious conditions that can cause similar symptoms. First, a physician or other practitioner should do a careful visual inspection of the area, looking for obvious ulcerations, genital warts, herpes sores, inflammation of the Bartholin's glands at the base of the vaginal opening or inflammation of the Skene's ducts on the external vulva.

He or she should take vaginal slides and cultures to rule out common and uncommon vaginal infections. In addition to slides for trichomonas, bacteria and yeast, it is important to rule out sexually transmitted diseases such as chlamydia and gonorrhea. Any unusual secretion from the urethra, the Bartholin's glands or the Skene's glands should be cultured, and a pap smear should be taken if any genital warts are noted.

It is also necessary to culture for unusual organisms such as ureaplasma or mycoplasma because these organisms often don't show up on a routine culture. In persons with urinary symptoms, urine and urethral cultures should be taken.

Urethral cultures are particularly important: sometimes a urethral infection will not show up on a urine culture and can greatly contribute towards the woman's pain. One physician also recommends testing the vaginal pH, since too much acidity in the vaginal secretions may contribute to vulvar inflammation.

The practitioner should take a cotton-tipped swab and gently touch various areas of the vulva to see if the pain can be localized to one area. Often, women who have previously described the pain as around the inner vaginal lips will find that the pain is actually in the hymen itself when the swab is used.

This is often a good time to educate women about vulvar anatomy. Many women believe that the hymen disappears after first sexual intercourse. Actually, this is not true: the hymen remains but is torn.

A woman can locate her hymen by taking a mirror and flashlight and inspecting the opening to the vagina. A woman who has had sexual intercourse before will probably notice several "petals", often described as flower-like, directly at the opening to the vagina.

A woman or girl who has never experienced vaginal penetration will usually find a kind of membrane or ring around the entrance to the vagina that considerably narrows the vaginal opening.

The practitioner should wipe the vulva with a mild solution of acetic acid read here: vinegar and water and then view it under a blue light to see if any areas turn white. These may be areas which have been infected with the Human Papilloma Virus HPV - although this is disputed; one paper suggests that acetic acid does not provide a very good guideline as to HPV infections. Depending on what is seen, a biopsy may be needed.

Biopsies in VVS often reveal inflammatory cells; however, at least one paper suggests that inflammatory cells can be seen in women who have no vulvar symptoms at all and thus may be a normal finding.

People researching the connection between vulvodynia and interstitial cystitis have recently developed an interesting test. One theory about painful urogenital syndromes is that the cell walls lining the mucosa of the area have become "leaky" and have altered permeability to potassium ions.

One study compared the infusion of small amounts of saline solution with potassium chloride of the same concentration in patients with interstitial cystitis, benign prostatic hypertrophy BPH , muscular contraction disorders detrusor instability , acute urinary tract infection and healthy controls. These researchers infused about mL of one solution into the bladder, removed it and then infused the same amount of the other solution and tried to see if the patient could tell the difference.

To quote their results: " Neither normal subjects nor patients with interstitial cystitis reacted to water administered intravesically. Only 1 patient with BPH responded to potassium and none of the 5 with chronic urinary tract infection responded. It may be of particular help to vulvodynia patients with urinary symptoms. Unfortunately, for most women with VVS, there are no magic cures. Sometimes an infection that will respond to medication is found, such as ureaplasma, candida, or strep.

In a lucky few, it clears up on its own after 6 - 12 months. Some women develop vulvar pain as part of the hormonal changes of menopause. This particular problem often responds to estrogen creams or estrogen replacement therapy. But for many women, the treatment is symptomatic, to try to reduce the pain. A prescription anesthetic, xylocaine available both as a jelly and a liquid solution , may be helpful if applied directly to the sore areas.

Unfortunately, the effects last only for a couple of hours and repeated applications can cause damage to the underlying skin. Xylocaine can very useful for intercourse, however, and also during pelvic examinations and sometimes during tampon changes. Some physicians are injecting xylocaine directly into the affected area to create a nerve block. The effects of a nerve block can last from a few hours to a couple of days. Unfortunately, the more often you inject a nerve, the less responsive it becomes to the anesthetic.

Topical corticosteroids are often prescribed for vulvar itching, but seem to be of little help in VVS. If the vagina is too acidic, one doctor recommends baking soda douches. This appears to help a few women, is inexpensive and non-toxic. Several studies have treated women who show also signs of HPV infection with interferon, which strengthens the immune system , with some success. Some gynecologists are treating VVS with hormones applied topically to the inflamed area.

Usually, these doctors are prescribing estrogen, but some are also using progesterone or testosterone which are accepted treatments for another vulvar pain condition called lichen planus. John Willems reports that he is having success with a kind of topical estrogen cream called Estrace.

Estrace is a 0. Willems works with many patients who have had laser excision of the vestibule with poor results. Willems believes that Estrace thickens or toughens the skin, and increases blood supply. He emphasizes that the patients he treats do not have clinical estrogen deficiencies nor are they menopausal.

Injection of hormones directly into the inflamed tissues should be avoided because most women find this to be too painful. Some women also find compresses made from prophyllin powder a prescription medication to be soothing.

Solomon and Melmed advise patients to try a diet low in oxalate. However, there is no reason to believe that harm will result from avoiding foods very high in oxalates, either. A list of high oxalate foods, along with their other dietary recommendations, is attached in Section X: List of foods high in oxalates. These doctors have been giving patients calcium citrate to see if neutralizing calcium oxalate helps vulvodynia. They are using a complicated method of charting the woman's peak times of oxalate production, and emphasize that patients should not try calcium citrate as a home remedy on their own, since it can be hazardous.

Another thing consistently reported by women with vulvar pain is that it helps to keep the urine diluted by drinking large amounts of liquids. It's not clear whether this helps by reducing the amount of oxalates in the urine, or if it's simply helpful because urine itself is irritating and dilute urine is less painful to inflamed tissues. Fibromyalgia researchers suggest that certain anti-depressant drugs may be of benefit to those women who also have FMS or who have vulvodynia involving neuralgia of the pudendal nerve.

This is because these drugs have pain controlling properties independent of their antidepressant effects via blocking pain impulses high in the spinal cord and are therefore sometimes of value in pain of neurogenic origin.

However, no controlled studies have been done of antidepressants for vulvar pain. Commonly used antidepressants include amitriptyline, nortriptyline, imipramine all tricyclic antidepressants and fluoxetine Prozac - an SSRI. There is also an anecdotal report that paroxetine Paxil is helpful with vulvar pain. Marinoff, however, believes that SSRIs are not particularly effective in treating vulvodynia.

Some physicians are experimenting with certain anticonvulsants known to work in other neurologic conditions involving shooting pains, such as trigeminal neuralgia a pain disorder of the face , herpes related "herpetic" neuralgia and phantom limb pain.

The most effective drugs for these conditions are carbamazepine Tegretol , gabapentin Neurotonin and clonazepam Klonopin. Another approach some doctors are trying for neurologic vulvodynia is the use of capsaicin. Capsaicin is an extract of red pepper that destroys certain peripheral nerve fibers. It's commonly used for neurologic pain from diabetes, HIV infection, herpes infection and other disorders that damage nerve tissue.

It is also used in the treatment of interstitial cystitis. Nine patients who applied capsaicin topically to the vulva for 6 weeks reported "significant relief". This study does not appear to have been published but it was presented at the first NIH Symposium on Vulvodynia. However, capsaicin also produces a significant burning sensation when applied to the skin. It may not be appropriate for patients with vulvodynia due to inflammation. Physical therapy may be of some help: not only do women often develop problems from the alterations of posture needed to avoid putting pressure on the vulva during walking and sitting, but it may be helpful by relaxing chronic tension in the pelvic muscles as well.

Howard Glazer, a psychologist in New York, claims that biofeedback and pelvic muscle exercises involving relaxation and muscle strengthening are helpful to some women with VVS. He proposes that vulvodynia may persist after an initial infection that has resolved. He believes that some women develop unconscious muscle tension in the pelvis and that this contributes to muscle spasm and pain perception.

He has published a study of 28 patients. Opiate and other standard pain relief drugs do relieve vulvar pain in high doses, according to Dr. Unfortunately, one effective treatment for neurologic pain cannot be used in vulvar pain: cutting the nerve causing the problem. The nerves that innervate the vulva also play a key role in bladder control.

Cutting the pudendal nerve results in urinary incontinence. However, the vulvar vestibule CAN be removed without causing incontinence. There are two main surgical procedures, which can be done either with laser or by traditional means: perineoplasty and vestibuloplasty.

In perineoplasty, the entire vulvar vestibule is removed, whereas in vestibuloplasty, the nerves that branch off the pudendal nerve directly to the vestibule are cut but most of the vestibular skin remains intact. Laser treatments burn off the affected tissue. There are reports that carbon dioxide laser causes bad burns and can worsen vulvodynia.

For this reason, some physicians feel very strongly that carbon dioxide laser should NEVER be used as a treatment. However, certain other laser treatments, such as dye laser are OK. A recent study attempted to find out who were the women most likely to improve from surgery or laser. They found that women who had an acute onset, relatively mild pain and whose pain was clearly localized to one area were most likely to benefit. Women whose symptoms were of short duration i.

Women with generalized vulvar pain are poor candidates for surgery or laser. Other researchers have concluded that women who have vulvar vestibulitis associated with pain with intercourse since their first episode of intercourse and in those with associated persistent vulvar pain will have a poor response to surgery.

They suggest that "treatment approaches other than surgery should be considered for such patients". Pregnancy and vulvar pain: Pregnancy can impact on vulvar pain in several ways. First, there is the problem of getting pregnant. Then there is the impact of the pregnancy before birth on vulvar pain and vice versa.

Next, there is the concern of pain relief during labor and delivery and finally, there is the impact of childbirth and vaginal delivery on the vulva in the postpartum period. Before the Pregnancy : Some of the medications women use to treat vulvar pain may cause birth defects. This is most true of the antidepressants.

If at all possible, these should be discontinued before trying to become pregnant. However, it is very important that a physician be consulted before discontinuing any medications. Do NOT wean yourself off antidepressants without a doctor's supervision. A: No risk demonstrated to the fetus in any trimester. B: No adverse effects in animals, no human studies available.

C: Only given after risks to the fetus are considered: animal studies have shown adverse effects; no human studies available. D: Definite fetal risks, may be given in spite of risks in life-threatening situations. Absolute fetal contraindications, not to be used any time during pregnancy. Physicians recommend that women discontinue Prozac, Zoloft or Paxil prior to becoming pregnant. In addition, women taking calcium citrate and following the low oxalate diet need to make some changes.

Marinoff states that doses of mg. However, higher doses can lead to kidney stones in the mother. This diet is lacking in many necessary nutrients for both fetus and mother. The mother may need to consult a registered dietitian for help in planning her diet. Becoming Pregnant: Next: how do you get pregnant if intercourse is too painful to tolerate?

It's best if the woman learns to detect when she is ovulating so that she can maximize her chances of becoming pregnant from one act of intercourse. The most commonly used methods for this are taking basal body temperature and observing the vaginal secretions for changes in the cervical mucus indicative of ovulation.